Study selection and assessment:

randomised controlled trials that compared thickened feeds with unthickened feeds; metoclopramide with no intervention or
placebo; or various positions in developmentally normal children 1–24 months of age with GER (diagnosed by signs or symptoms
or pH monitoring). 3 independent reviewers assessed the methodological quality of individual studies using the Jadad scale.

Outcomes:

signs and symptoms of GER (regurgitation, respiratory symptoms, and weight gain), reflux index (percentage of total time oesophageal
pH <4), number of reflux episodes, number of reflux episodes lasting >5 minutes per unit time, adverse effects such as coughing
(thickened feeds) and fussiness, drowsiness, and extrapyramidal reactions (metoclopramide).

5 crossover trials (median sample size 15; 2 had Jadad scores ⩾3/5) assessed variations in positioning. The findings of 4 trials (1983–97) that assessed various prone positions are not summarised here because of more recent
findings that such positioning is associated with an increased risk of sudden infant death syndrome, and subsequent recommendations
that infants should be placed in a supine position. 1 trial (n = 10) found no difference between horizontal and elevated supine
positioning.

CONCLUSIONS

In healthy infants 1–24 months of age with gastro-oesophageal reflux, thickened feeds may reduce symptoms, but are also associated
with increased coughing. Some evidence suggests that metoclopramide may reduce symptoms. Evidence from 1 small trial suggests
that supine positioning with head elevation does not differ from horizontal positioning.

Commentary

GER, the back flow of gastric contents into the oesophagus, afflicts 50% of infants aged 0–3 months; this drops to 5% once
infants are 10–12 months of age.1 3% of parents of 10–12 month old infants view this as a problem.1

The systematic review by Craig et al included a comprehensive search for all published randomised controlled trials and used 3 reviewers to independently assess
the quality of each study and to extract data. The review could have been strengthened with the inclusion of unpublished studies
and consideration of the influence of method of infant feeding (ie, bottle or breast feeding) on study results, and ultimately,
conclusions. Breastfed babies are known to have shorter episodes of GER than formula fed infants.2

Information gleaned from this review may be useful for nurses who advise pregnant parents, as well as nurses who provide guidance
to parents of infants with GER. Thickened feeds may be somewhat helpful in reducing the symptoms of GER, although the American
Academy of Paediatrics recommends exclusive breast feeding for the first 6 months of life and discourages the introduction
of solid foods before the recommended age.3 Although prone and left sided positioning decrease the reflux index compared with supine positioning, these positions are
associated with a higher risk of sudden infant death syndrome4 and therefore are not recommended. Prokinetic agents such as metoclopramide may have only some benefit in treating symptomatic
GER but also put the child at risk of adverse drug effects.

Explaining to parents that GER will subside on its own over time without treatment and that interventions may have only limited
effects may give them the encouragement they need to weather the GER storm with their infants. Indeed, the safest treatment
for infants with GER may be reassurance from a knowledgeable professional. However, poor infant weight gain or growth retardation
signals the need for more aggressive intervention.